ACP InternistWeekly

In the News for the Week of August 28, 2012

Highlights

Almost 40% of medical visits for primary care services were to non-primary care physicians, a new study found. More...

2012 a bad year for West Nile virus

West Nile virus has been more active in 2012 than in any year since the disease was first detected, the CDC recently reported. More...

Test yourself

MKSAP Quiz: fatigue and dyspnea in an elderly man

This week's quiz asks readers to evaluate a 72-year-old man for fatigue and dyspnea. More...

Screening

Little evidence on screening for CKD, USPSTF says

The current evidence is insufficient to determine whether asymptomatic patients should be screened for chronic kidney disease
(CKD), according to a new recommendation from the U.S. Preventive Services Task Force (USPSTF). More...

Commercial screening tests not always indicated, ethical

Commercial screening tests marketed directly to the consumer are not always indicated or ethical, according to a recent opinion
piece. More...

Perioperative care

Eltrombopag, an oral thrombopoietin-receptor agonist, may reduce the need for platelet transfusions in patients with thrombocytopenia
and chronic liver disease who are undergoing invasive elective procedures, but risk for portal-vein thrombosis may increase,
according to a new industry-funded study. More...

Education

Correctional health care conference to be held in October

The National Commission on Correctional Health Care will hold its national conference Oct. 20-24 in Las Vegas. More...

Highlights

Almost 40% of medical visits for primary care services were to non-primary care physicians, a new study found.

Researchers performed a cross-sectional analysis of data from the National Ambulatory Medical Care Survey (NAMCS), examining
over 8,000 and 12,000 visits, respectively, in 1999 and 2007. Visits for primary care services were determined by using the
Reason for Visit code, which represents the patient's complaint, symptom, or other reason for the visit in the patient's own
words, and classified these visits into those related to common symptoms or diseases (such as fever, nasal congestion, or
asthma), or for general preventive care. The surveyed physicians were categorized into four groups: primary care physicians,
internal medicine subspecialists, obstetricians/gynecologists and all other specialists. The results were published as a research letter by Archives of Internal Medicine on Aug. 20.

Overall, the study found no significant change in the type of physician patients saw for these primary care visits between
1999 and 2007. In both 1999 and 2007, 59% of the common/preventive visits were made to primary care physicians. Internal medicine
subspecialists saw about 9% of the visits, OB-GYNs about 4%, and other specialists about 28%. For the common symptom or disease
visits specifically, the percentages were: 58% primary care, 9% medicine subspecialties, 3% OB-GYNs and 30% other specialists.
Over the study period, there was a nonsignificant increase in preventive exams by primary care and internal medicine subspecialties,
and a decrease in those by OB-GYNs or other specialists.

The study authors concluded that these findings raise concerns about inefficiencies between primary care physician supply
and demand. They offered two possible explanations: patients' preference for specialty care and the shortage of primary care
physicians in the U.S. They called for additional research to better determine the causes of these findings and for improvements
to create a better coordinated health care system.

2012 a bad year for West Nile virus

West Nile virus has been more active in 2012 than in any year since the disease was first detected, the CDC recently reported.

As of August 21, a total of 38 states had reported human cases of West Nile virus infection, with nine other states reporting
it in birds or mosquitoes, according to a CDC telebriefing. The only states not reporting activity were Alaska, Hawaii and
Vermont. A total of 1,118 cases in people, including 41 deaths, had been reported to CDC. Of these, 56% were classified as
neuroinvasive disease and 44% were classified as non-neuroinvasive disease.

Approximately 75% of the cases came from five states: Texas, Mississippi, Louisiana, South Dakota and Oklahoma, with Texas
being particularly hard-hit, CDC officials said. Reports appear to be still on the increase in most areas, including Texas.
The peak of infections usually occurs in mid-August, but there is some delay in reporting. Officials were uncertain why the
virus is more active this year, although they suggested the unusually mild winter, early spring and hot summer may have created
favorable conditions.

There are no medications or vaccines for West Nile virus infection, a CDC press release noted. Patients with milder illnesses typically recover on their own, but patients with more severe cases often need to be
hospitalized to receive supportive treatment, such as intravenous fluids, pain medication, and nursing care.

The experts urged the public to use insect repellents, wear long sleeves and pants during dawn and dusk, install or repair
screens on windows and doors, use air-conditioning, and empty standing water from areas around the home to reduce the risk
of infection. A viewpoint published by the Journal of the American Medical Association on Aug. 24 offered additional information about West Nile virus.

Test yourself

MKSAP Quiz: fatigue and dyspnea in an elderly man

A 72-year-old man is evaluated for fatigue and dyspnea. Over the last several months to a year, he has had increasing fatigue,
exercise intolerance, and dyspnea on even mild exertion. He becomes short of breath walking across a room, although he is
asymptomatic at rest. He denies chest pain, palpitations, syncope, orthopnea, and lower extremity edema. He has a history
of coronary artery disease, with a myocardial infarction and four-vessel coronary artery bypass graft surgery 4 years ago.
He also has hyperlipidemia and type 2 diabetes mellitus. Medications are aspirin, low-dose carvedilol, lisinopril, digoxin,
spironolactone, furosemide, pravastatin, and glyburide.

On physical examination, his blood pressure is 92/57 mm Hg, pulse is 57/min, and respiration rate is 12/min. Cardiovascular
examination reveals a point of maximal impulse that is displaced laterally. Rhythm is regular and bradycardic. S1 and S2 are
normal, with a grade 2/6 to 3/6 holosystolic murmur at the apex. An S3 is present. Estimated central venous pressure is 8
cm H2O; there is no hepatojugular reflux. The lungs are clear. There is no ascites. The liver edge is palpable 1 cm below the right
costal margin. The lower extremities are warm with decreased distal pulses bilaterally. There is no ankle edema.

Electrocardiogram demonstrates sinus rhythm with a rate of 55/min. PR interval is 180 msec, QRS width is 180 msec, and QT
interval is 380 msec. Left bundle branch block is seen. A dobutamine stress echocardiogram reveals a left ventricular ejection
fraction of 33% with a large anteroapical area of akinesis and no ischemia.

Which of the following is the most appropriate management option for this patient?

Screening

Little evidence on screening for CKD, USPSTF says

The current evidence is insufficient to determine whether asymptomatic patients should be screened for chronic kidney disease
(CKD), according to a new recommendation from the U.S. Preventive Services Task Force (USPSTF).

The USPSTF statement was published online Aug. 28 Annals of Internal Medicine. The recommendation is focused only on screening asymptomatic individuals and does not apply to testing for and monitoring
CKD for the purpose of chronic disease management (including monitoring patients with diabetes or hypertension), the task
force noted. Evidence shows that CKD treatments for patients with diabetes reduce risk, and although there is limited evidence
on whether CKD screening in patients with isolated hypertension changes treatment decisions, several organizations recommend
screening.

The benefits of testing asymptomatic patients are uncertain because no studies have evaluated the sensitivity and specificity
of one-time testing by either serum creatinine or urine albumin. There is also no evidence on the benefits of early CKD treatment
in persons without diabetes or hypertension. However, convincing evidence shows that medications used to treat early CKD may
have adverse effects, the USPSTF wrote. Other potential harms include adverse effects from venopuncture and psychological
effects of labeling a person with CKD.

The task force noted that serum creatinine testing is widely done for various reasons in clinical practice, but that no guidelines
from primary care organizations recommend screening all adults for CKD. They called for additional research, including on
sensitivity and specificity of testing and possible interventions to reduce end-stage kidney disease among African-Americans.

The authors acknowledge that some commercial screening tests have proven benefit but note that the way in which the tests
are administered, outside the physician's office and without a physician's advice, can be problematic. Consumers may not be
aware that an "abnormal" result on a screening test may lead to many more additional referrals and tests, they said.

Ethical considerations mandate the following minimum standards, they wrote:

Direct-to-consumer screening companies should state openly for whom screening tests are indicated according to published,
evidence-based guidelines.

Companies should fully inform customers about the potential risks and benefits of positive and negative results before tests
are performed.

Medical organizations, hospitals and physicians should not sponsor health screenings by commercial companies that offer unproven
or harmful testing, as doing so represents a clear conflict of interest.

"If screening asymptomatic persons in the general population with nonindicated tests neither is medically beneficial nor enhances
behavior change, how can it be ethical to allow marketing of such tests to the public?" the authors wrote. "We believe that
promoting and selling nonbeneficial testing violates the ethical principles of beneficence and nonmalificence."

The authors stressed that they respect patients' autonomy to make their own decisions but said that these decisions should
be informed by evidence.

"Judicious and appropriate use of preventive services can certainly improve the health of our population and lower overall
health care costs. However, misuse of preventive services, under the guise of saving lives and saving costs, may actually
lead to increased cost and harm due to unnecessary follow-up testing and treatment with associated avoidable complications,"
the authors wrote. "We suggest that medical entities and physicians withdraw from the unethical business of promoting unproven
and potentially harmful screening tests."

The full text of the article, which was published Aug. 28 by Annals of Internal Medicine, is available online. More information on ACP's High Value, Cost-Conscious Care Initiative is available on the College's website.

Perioperative care

Eltrombopag, an oral thrombopoietin-receptor agonist, may reduce the need for platelet transfusions in patients with thrombocytopenia
and chronic liver disease who are undergoing invasive elective procedures, but risk for portal-vein thrombosis may increase,
according to a new industry-funded study.

Researchers randomly assigned 292 patients with chronic liver disease and platelet counts below 50,000 mm3 to receive a 14-day course of eltrombopag, 75 mg/d, or placebo before undergoing an elective invasive procedure, which was
done within five days of the last drug dose. The study's primary end point was whether platelet transfusions were avoided
before, during and up to a week after the procedures. Bleeding during this period was a key secondary end point, and other
adverse events were also assessed. Results of the study, which was funded by GlaxoSmithKline, appeared in the Aug. 23 New England Journal of Medicine.

One hundred forty-five patients were assigned to the eltrombopag group, and 147 were assigned to the placebo group. The median
patient age was 53 years. Most patients were men, and most were white. Overall, 104 patients in the eltrombopag group (72%)
and 28 in the placebo group (19%) avoided a platelet transfusion (P<0.001). Bleeding episodes did not differ significantly between the two groups, and rates of most other adverse events
were also similar. Portal-vein thrombosis, however, occurred more frequently in the eltrombopag group than in the placebo
group (six patients vs. one patient), and the study was terminated early as a result.

The authors concluded that patients with chronic liver disease who received eltrombopag before an elective invasive procedure
were less likely to require platelet transfusion but appeared to have an elevated risk of portal-vein thrombosis. They called
for further studies of eltrombopag therapy to better identify risk factors for thrombosis, appropriate dose and appropriate
patients. "Until such studies have been conducted, eltrombopag is not recommended as an alternative to platelet transfusion
in patients with chronic liver disease and thrombocytopenia who are undergoing an elective invasive procedure," the authors
wrote.

Education

Correctional health care conference to be held in October

The National Commission on Correctional Health Care will hold its national conference Oct. 20-24 in Las Vegas.

The conference is designed to help correctional health professionals create opportunities to advance the care provided in
their facilities. Preconference seminars will focus on fundamentals in correctional health care, while concurrent sessions
will feature presentations on medical care, nursing, cost containment, legal issues and mental health care, among other topics.

ACP is a supporting organization of the National Commission on Correctional Health Care. For more complete information, visit
the commission website, call 773-880-1460, or send an e-mail.

From the College

The CDC awarded ACP with an initial $175,000 grant for 2012-2013 to create a three-year evidence-based program to increase
adult immunization rates in five states.

Working with ACP chapters in Arizona, Delaware, Northern Illinois, Maryland and New York, the program will assist up to 100
internal medicine practices in implementing strategies for improving adult immunization rates toward the federal government's
goals for 2020, including seasonal influenza immunization of 80% to 90% of adults. The three-year program will focus on increasing
adult immunization rates and clinical team education, practice assessment and performance feedback, increasing clinician recommendation
of immunization to patients, and implementation of standing order protocols from attending physicians.

MKSAP Answer and Critique

The correct answer is B) Biventricular pacemaker-defibrillator. This item is available to MKSAP 15 subscribers as item 5 in
the Cardiology section.

MKSAP 16 released Part A on July 31. More information is available online.

This patient has worsening heart failure symptoms (New York Heart Association [NYHA] class III) despite a good heart failure
medication regimen. In addition, he has an increased risk of sudden death due to ischemic cardiomyopathy. Implantation of
a biventricular pacemaker-defibrillator may afford him both symptomatic benefit and a reduced risk of death. The indications
for biventricular pacemaker-defibrillator placement include NYHA class III or IV heart failure, an ejection fraction less
than or equal to 35%, and a QRS width greater than 120 msec. Approximately 70% of patients who undergo biventricular device
placement obtain a symptomatic benefit, thought to result from mechanical "resynchronization" of the timing of right and left
ventricular contraction. These devices have been shown to improve ejection fraction, quality of life, and functional status,
as well as to decrease heart failure hospitalizations and mortality.

Amiodarone does not improve symptoms of heart failure or decrease mortality and therefore would not be of use in this patient.

This patient is a candidate for an implantable defibrillator for prevention of sudden death. However, a single-lead primary
prevention device will not provide amelioration of his symptoms. A dual-chamber (atrioventricular) pacemaker-defibrillator
would provide additional protection from sinus bradycardia by atrial pacing, while the defibrillator portion would reduce
his risk of sudden death. Although a conventional dual-chamber pacemaker may allow increases of β-blocker dosage, there
is no evidence that such a strategy results in improved cardiovascular outcome in patients treated for heart failure and it
will not by itself provide symptomatic benefit or protect the patient from ventricular arrhythmia and sudden death. Additionally,
some dual-chamber defibrillators oblige right ventricular pacing, which can cause worsening of heart failure symptoms and
increase hospitalization for heart failure.

Key Point

A biventricular pacemaker-defibrillator may provide symptomatic and mortality benefit in patients with ejection fraction less
than or equal to 35%, QRS width greater than 120-130 msec, and New York Heart Association class III or IV heart failure.

Test yourself

A 66-year-old man is evaluated for a persistent rash for 6 years' duration. The rash waxes and wanes in severity, and it becomes pruritic only after he becomes hot and sweating, such as when he mows the lawn or exercises. It has always been limited to his back and lower chest. He has never treated it. The patient is otherwise well, has no other medical problems, and takes no medication. Following a physical exam, what is the most likely diagnosis?

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